FOCUS ON FIBROMYALGIA.

Muscle pain is only part of the problem facing millions of Americans living with fibromyalgia, a condition virtually unheard of 20 years ago. A thorough medical evaluation can often point to helpful strategies for dealing with the chronic ailment.

Day in and day out, millions of Americans wake up to debilitating musculoskeletal pain and severe fatigue. Until recently, physicians were perplexed by the mysterious illness because objective, physiologic evidence from x-rays, blood tests, and other diagnostic screenings looked normal. The patient's symptoms were frequently attributed to psychological origins.

During the past decade, however, researchers have discovered that the symptoms are linked to a very real ailment known as fibromyalgia, estimated to affect some 3 million Americans, most of whom are women between 20 and 50 years old. Fibromyalgia refers to pain in the muscles, ligaments, and tendons in the body. Although muscular pain and fatigue are hallmarks of the disorder, other symptoms include irritable bowel syndrome, chronic headaches, temporomandibular joint dysfunction, and chemical sensitivity syndrome, among others.

While the cause of the disorder is as yet undetermined, fibromyalgia is being intensely studied, and investigators are learning more about how patients can cope.

The Post interviewed Dr. Dale Guyer, who treats many patients with fibromyalgia and chronic fatigue syndrome in his clinic.

Q: Fibromyalgia is getting much more attention from doctors who treat the disorder and the individuals who suffer from it. What is fibromyalgia? Is it related to chronic fatigue syndrome?

A: We often find in many people that chronic fatigue syndrome and fibromyalgia are intertwined. Some people express more in one direction than the other. In my practice, many people have elements of both disorders.

Fibromyalgia is frequently described as a general "hurting all over." There are specific diagnostic criteria involving 11 out of 18 tender points on different areas of the body, starting at the base of the skull and involving the back, the inner arms, thighs, and so forth. In addition, fibromyalgia usually lasts longer than three months and is often accompanied by sleep disturbances and other miscellaneous symptoms. People with fibromyalgia may also complain of fatigue that at times warrants a diagnosis of chronic fatigue syndrome.

Chronic fatigue is a generalized, debilitating, longstanding fatigue that dramatically encroaches into a person's ability to participate in the activities of daily living.

Q: What are tender points?

A: Tender points in fibromyalgia are part of the diagnostic criteria. Many people don't even recognize that they have tender points until a doctor actually pushes on those points. Patients can literally jump off the table because these areas are so tender.

These tender points are pretty well documented. Any good book on fibromyalgia will clearly explain them. For readers who want a very good reference work on fibromyalgia and chronic fatigue syndrome, especially one that encompasses many alternative treatments, Dr. Jacob Teitelbaum's book From Fatigued to Fantastic! is an excellent resource. It even has really nice cartoons, has an illustration of the tender points, and can be an invaluable resource for anyone suffering from this illness. It can provide tools that have real therapeutic potential.

Q: Are these tender points the result of inflammation?

A: The role of inflammation remains unclear. There is uncertainty if fibromyalgia is purely inflammatory because there are generally numerous metabolic issues that can be involved. Because of that, anti-inflammatory medicines will work for some people, but not for others.

Q: What causes fibromyalgia and chronic fatigue syndrome?

A: We really don't know as yet the cause of chronic fatigue or fibromyalgia, Typically, we first exclude other potential diagnoses, such as autoimmune disorders, digestive disorders, musculoskeletal problems, and even cancers can sometimes mimic some symptoms of chronic fatigue and fibromyalgia. After we exclude other disorders, we can more comfortably diagnose fibromyalgia or chronic fatigue syndrome as a diagnosis of exclusion.

Therapy for both generally focuses on symptom control. Anti-inflammatories may help with pain; stimulants sometimes help improve energy, and other medicines improve sleep. Certain antidepressant drugs, such as Prozac and Serzone, often help with the depression that many people with these conditions feel, and the antidepressants can improve some patients' pain control.

Q: What are some of the most common complaints and characteristics of this syndrome in cases that you see?

A: With my patients, I do a global evaluation to understand underlying problems. For example, if we were looking at someone with chronic fatigue syndrome and fibromyalgia, we would look at what is going on metabolically with the individual. I often see low thyroid function, endocrine abnormalities, hormonal problems, deficiencies (even for women) of testosterone and DHEA, adrenal insufficiency, accumulation of toxic metals. Many individuals will measure quite high on toxic metals that may play a very strong inflammatory role, such as aluminum, cadmium, mercury, and lead.

Low thyroid function is commonly associated with chronic fatigue and fibromyalgia, even though results from lab tests are within normal range; the levels are often low normal. Lab tests only measure a hormone level; they don't really tell you anything about the functional state or activity of the hormone. The tests don't tell you even how receptive your body's tissues are to the thyroid hormones.

When we determine what a normal laboratory value is for a particular test, in this case thyroid hormone levels, we are sampling the general population. From that mass sampling, we determine what is average. But if we are sampling many people out there, many of them don't feel well. A list of thyroid symptoms includes: fatigue, PMS, dry skin, brittle nails, weight gain, difficulty with weight loss, depression, low motivation, feeling cold all the time, and constipation. In my practice I've seen a number of individuals with thyroid symptoms, and yet their lab tests were normal. A low dose of a natural thyroid extract, such as Armour Thyroid, can literally be life-changing in many of these patients.

Infectious processes can also be involved. Certain types of fungi--such as Candida albicans, other bacterial organisms, imbalances in the digestive tract of friendly and unfriendly bacteria, poor digestive process, immune dysfunction problems--may be involved. We can often measure viral problems, such as Epstein-Barr virus, HHV6 (human herpesvirus type 6), CMV, and others that have a clear association. Evaluating the nutritional status is also important. Many people with fibromyalgia display a nutritional deficit in minerals, such as magnesium or calcium, as well as deficiencies in some of their antioxidants--especially coenzyme [Q.sub.10] and vitamin E.

During the evaluation, you begin to understand what areas are imbalanced in an individual. You can then correct the imbalance by giving the body what it is lacking. In this way, you create a body environment conducive to health and healing. The body is usually quite capable of taking care of itself. Our goal is only to provide the environment for that natural reaction to occur.

Q: A global evaluation would take a great deal of time and concentrated effort.

A: That can be a challenge, which is one reason that I referred Post readers to the book From Fatigued To Fantastic/, which offers a general overview of the disorder. They can take this information to their physicians. It is true that meeting with a physician is often limited to an average six-minute visit. And for someone with a serious, chronic illness such as fibromyalgia or chronic fatigue syndrome, proper diagnosis and treatment cannot be found in a brief office visit.

I have worked with many individuals with fibromyalgia and/or chronic fatigue syndrome, and each one is different. There are common themes that show up in a person's medical history. Some may start out with a simple hip or muscle pain that spreads. Viral infection is a very common piece of medical history that shows up in an individual. A typical scenario might read: I was doing really well in my life until three years ago when I got this really nasty flu. Ever since then, I have intermittent, cyclic phenomena of flulike symptoms.

Q: Are there foods that help patients with symptoms?

A: The main focus in these disorders is to make sure that you are consuming several servings a day from the large array of foods that are bright in color. The American Cancer Society usually recommends at least six servings of multiple types of fruits and vegetables. Eat your fruits and vegetables.

Q: Is being overweight something that you consistently see in your fibromyalgia patients?

A: Weight is a health problem in many arenas, including fibromyalgia. Obviously, excess weight increases the risk for other types of chronic illness--arthritis, heart disease, and cancer. And extra weight puts pressure on the body, especially the joints. A vicious cycle can set in. Here is someone who hurts all the time and may benefit from exercise, yet exercise can at times exacerbate the pain. We know that exercise improves the circulation and the overall functioning of the body--and releases natural painkillers and anti-inflammatories. In the long run, exercise actually will help improve the condition. Exercise is probably the most cost-effective medicine going. If you look at things not yet controlled by the FDA, exercise, prayer, and laughter are probably the big three.

Q: What about massage?

A: Massage works well for patients with fibromyalgia, with one exception. Many people with fibromyalgia are unable to tolerate deep muscle massage that can stimulate release of toxins in the body; it can sometimes make them feel worse. Initially, patients will feel better with what we might define as a Swedish or "Love Boat" massage with lighter tactile pressure. Individuals need to find out what works most effectively for themselves.

Q: What toxins are released in the body by massage?

A: We look at the possible release of chemical toxins, aromatic hydrocarbons, or heavy metals, among others.

Q: Do toxins rest in the muscles?

A: Yes, they do, actually.

Q: Wouldn't you want to get those toxins out?

A: Yes, you absolutely would. A detoxification therapy that we didn't mention is the sauna. New infrared-based saunas are available which can be very helpful in detoxificatiod and can easily be installed in the home.

To order a video of Dr. Guyer's comments on fibromyalgia and an interview with Lise Hoffman, a young woman who is learning to cope with this disorder, send $19.95 (includes s&h) to: The Saturday Evening Post Video Library, P.O. Box 1144, Dept. 1199, Indianapolis, IN 46206-1144, or call 1-800-558-2376.

RELATED ARTICLE: Diagnosing Fibromyalgia

People with fibromyalgia have multiple tender points in specific muscle areas. Most individuals complain of aching and stiffness in areas around the neck, shoulders, upper back, lower back, and hip areas. Many patients have no underlying disorders, while others who develop fibromyalgia may have conditions such as rheumatoid arthritis, spinal arthritis, or Lyme disease. Diagnosis is based on the patient's description of chronic widespread pain and the finding of tender points at specific locations by a physician. There are no blood or x-ray tests that are abnormal in fibromyalgia.

Common conditions that may mimic fibromyalgia include hypothyroidism, lupus, rheumatoid arthritis, and infections. Examination and laboratory tests can usually exclude these conditions. People with fibromyalgia often need a rheumatology consultation to determine the cause of multiple rheumatic symptoms, to be educated about fibromyalgia and its treatment, and to exclude other potentially progressive rheumatic diseases. A treatment program must be planned to meet the patient's needs.

To find a rheumatologist in your area, check the American College of Rheumatology Web site at www.rheumatology.org or call 404-633-3777. The Fibromyalgia Network can be reached at 520-290-5508.

--American College of Rheumatology